Dear Potential Provider:

Transcription

1 Dear Potential Provider: Thank you for speaking with us in regard to providing interpretation services for ProCare. We specialize in arranging transportation and language services for Worker s Compensation claimants. Enclosed is our New Provider Packet with our Provider Application and Agreement, to be completed and returned to us along with the required credentialing documents as soon as possible. Please remember to check on your Application whether you are Commercial or an Independent. A checklist of the needed documents for each provider type is provided below for your convenience. If you have any questions, please contact Provider Relations by ing ProviderRelations@theprocare.com or call us toll-free at (866) , and select Option 5 for Provider Relations when prompted. We will be happy to assist you. We look forward to working with you. Sincerely, Provider Relations ProCare Transportation and Language Services Send copies of the following documents to: Provider Relations Department ProviderRelations@theProCare.com Fax: (813) Document Checklist for Commercial Providers: Document Checklist for Independent Providers: Interpretation Application and Agreement (initial in bottom right-hand corner of each page) Interpretation Provider Rate Sheet W-9 Form Business/Occupational License Certificate of Professional Liability Insurance (preferably on the Acord Form 25 with ProCare named as the Certificate Holder) Interpretation Application and Agreement (initial in bottom right-hand corner of each page) Interpretation Provider Rate Sheet W-9 Form Resume or Curriculum Vitae Proof of Certification or Any Language Qualifications Earned (if applicable)

2 Please keep the following service terms in mind when providing services for ProCare: *Interpreter s appearance must be professional at all times. *Interpreter should arrive at the appointment 15 minutes prior to the scheduled appointment. *Interpreter must report any issues or changes regarding the assignment to ProCare immediately. *If Interpreter arrives to the assignment and claimant is a no show, Interpreter must notify ProCare immediately. ProCare must authorize Interpreter to be released to guarantee payment of no show fee. *Interpreter must maintain objectivity and impartiality at all times during an assignment. *Any requests or fees not listed on the authorization must be reported to ProCare for approval before proceeding in order to guarantee payment. *Final appointment length and/or any additional authorized fees must be reported to ProCare within 24 hours of completion of the assignment. Appointment information received more than 72 hours after the assignment will be adjusted on the invoice to Contracting Provider s minimum hourly rate. *The claimant or any party other than ProCare shall not be asked for payment or tip money. *All information about the claimant, including any legal or financial matters, must be kept confidential. Confirmation Process for Services that have been assigned to you (excluding Rushes): *You will receive an from ProCare in the morning 1 day before your scheduled assignment to confirm that all assignment information is on schedule. *You MUST CLICK on either the GREEN CONFIRM COVERAGE BUTTON or the RED UNABLE TO COVER BUTTON in the to confirm your coverage of the assignment, or advise ProCare that you are unable to cover the assignment. *After your selection, you will see a Confirmation Screen letting you know that ProCare received your selection. Once you confirm, you will not be contacted by ProCare again to confirm this assignment unless there are changes to the assignment. - ProCare will attempt to CALL you if we are unable to confirm via . - If ProCare is still not able to confirm your coverage of the assignments for the next day, the assignment may be reassigned to another provider. If you have a question regarding these service terms, please ProviderRelations@theprocare.com. If you have a question about an assignment that was sent to you, please Dispatch@theprocare.com.

3 INTERPRETATION PROVIDER APPLICATION PROVIDER TYPE (CHECK ONE): COMMERCIAL INDEPENDENT PROVIDER NAME: ADDRESS: CITY: STATE: ZIP: PHONE NUMBER: ALTERNATE NUMBER: FAX NUMBER: TAX IDENTIFICATION NUMBER: PLEASE LIST KEY PERSONNEL: Scheduler: Phone: Manager: Phone: Billing Coordinator: Phone: Contract Coordinator: Phone: REGULAR HOURS OF OPERATION: Monday Friday: A.M. TO P.M. Saturday/Sunday: A.M. TO P.M. Holidays: CONTACT FOR AFTER HOURS SCHEDULING OR EMERGENCY: Name: Phone:

4 PROVIDER AGREEMENT This Agreement is made by and between ProCare, Inc., (hereinafter referred to as "ProCare"), and (hereinafter referred to as "Contracting Provider"). GOVERNING LAW The laws of the State of Florida shall govern this agreement. Venue for any dispute between the parties shall be in the Courts of Hillsborough County, Florida. TERM AND TERMINATION This agreement shall be effective for one year, and after the initial term, shall automatically renew for successive one-year terms, without notice, unless either party gives written notice of termination at least ninety (90) days prior to the expiration date of the agreement or any extension thereof. Contracting Provider shall continue to provide service through the end of the notice period without decline in service standards and availability. ProCare may terminate this agreement at any time in the event of fraud, abandonment, or gross or willful misconduct on the part of the Contracting Provider, or if the Contracting Provider fails or refuses to meet its obligations and/or the Terms of Service outlined in this agreement. In the event Contracting Provider elects to terminate service without notice, Contracting Provider shall be responsible for any costs in the excess of the Contracting Provider s rates as outlined in the Rate Sheet (Fee Schedule) incurred by ProCare in the servicing of the Contracting Provider s service area. SERVICE AREA The general service area for this agreement shall be County within the State of. (Indicate specific coverage area information on the Provider Fee Schedule). The boundaries of the service area may be adjusted from time to time via amendment to the Provider Fee Schedule. TERMS OF SERVICE Contracting Provider agrees to participate as an interpretation provider in ProCare s provider network in accordance with all the applicable terms of this Agreement, including, but not limited to, the following: (Any deviation from these Terms of Service may affect Contracting Provider s payment.) 1) Rates must be pre-determined and finalized at time of acceptance of assignment. Additional fees submitted at a later date and/or time may be subject to denial. TL - 2 Initial

5 2) Contracting Provider agrees that any and all services completed for ProCare will be rendered by Contracting Provider s own interpreters. Transferring services that ProCare assigned to the Contracting Provider to another provider is prohibited. 3) Contracting Provider agrees to arrive at each appointment 15 minutes prior to the scheduled appointment. If Contracting Provider is running late, or can t make the appointment, Contracting Provider must notify ProCare immediately. Upon arrival at the facility, Contracting Provider must identify himself/herself as the ProCare interpreter assigned to the injured worker to the injured worker, physician and/or case manager. 4) Contracting Provider agrees to contact ProCare immediately if the injured worker does not arrive within 15 minutes of the scheduled appointment, or if the scheduled appointment will require a prolonged wait time (longer than 30 minutes). 5) Contracting Provider agrees to maintain objectivity and impartiality during all assignments. Contracting Provider must communicate in a thorough and precise manner. Contracting Provider may only ask questions of the physician, case manager, therapist, etc., that are posed by the injured worker or one of the above. 6) Contracting Provider s appearance must be professional at all times, i.e., collared shirt/blouse, slacks or skirt, and dress shoes. (No sneakers, sandals, jeans, shorts, T-shirts, etc. allowed.) Contracting Provider s clothes must be clean and pressed. 7) Contracting Provider agrees to notify ProCare immediately of any incident involving an injured worker. 8) Contracting Provider agrees to cooperate and participate with and in, and be bound by, ProCare policy and procedures, quality assurance, record keeping, audit and grievance procedures. 9) Contracting Provider shall not contact, solicit or seek payment from injured workers or ProCare Clients (i.e., claimant s case manager and/or adjuster). Rates and/or payment shall only be discussed with ProCare. 10) Contracting Provider s staff or agents shall not at any time discuss financial or legal matters or advise injured worker to seek the services of an attorney or medical provider or to provide the name and/or telephone number of such Service Providers. 11) Contracting Provider agrees to accept injured worker without discrimination based upon age, sex, race, color, religion, national origin, or the medical nature of the illness involved. 12) Names, addresses, phone numbers, etc., of claimants serviced by Contracting Provider on behalf of ProCare are the property of ProCare and shall not be distributed for any purpose. 13) Contracting Provider shall not solicit or entice injured workers with any incentives, discounts or gifts in order to maintain or increase patronage, or to encourage a ProCare injured worker to select or request service by a Provider other than ProCare. TL - 3 Initial

6 INTERPRETER STANDARDS Contracting Provider agrees that all of its interpreters will meet and maintain the following Interpreter Standards: 1) Be fluent in English and the target language. 2) Be able to interpret effectively, accurately, and impartially. 3) Be able to understand and present information of a medical nature. 4) Accreditation by a recognized interpretation entity or completion of a recognized medical interpreter course is preferred. 5) Bachelor s Degree is preferred. 6) A minimum of 2 years experience in medical interpretation is preferred. Contracting Provider agrees to monitor its interpreters to ensure their compliance with the Interpreter Standards. Contracting Provider agrees to permanently remove any interpreters found to be in violation of the Interpreter Standards from its interpreter roster to ensure that interpreter is not utilized for ProCare. Contracting Provider agrees to maintain a zero-tolerance drug and alcohol policy with its interpreters. Contracting Provider agrees to permanently remove any interpreter found to be in violation of the drug and alcohol policy from its interpreter roster to ensure that interpreter is not utilized for ProCare. Contracting Provider also agrees to notify ProCare promptly of any drug- or alcohol-related incidents or complaints involving its interpreters and ProCare claimants. Contracting Provider understands that failure on its part to ensure its interpreters are meeting and maintaining the Interpreter Standards may result in the Contracting Provider s suspension or termination from ProCare s provider network. REGULATORY COMPLIANCE It is the sole responsibility of the Contracting Provider to be informed of and to comply with any and all Federal, State, County, or Local Laws, statutes and ordinances which regulate or oversee the Contracting Provider s business segment. Contracting Provider shall notify ProCare within one (1) business day of notification of lack of compliance by any regulatory body. INVOICING / PAYMENT OF SERVICES Contracting Provider agrees to look solely to ProCare for payment for services provided under this Agreement. Contracting Provider must submit an invoice to ProCare for each service in order to be paid. ProCare shall only be obligated to pay Contracting Provider for services authorized by ProCare. Failure to comply may result in nonpayment. No advance billing will be accepted. ProCare agrees to pay clean claims within thirty (30) days of ProCare s receipt of a clean invoice from the Contracting Provider. ProCare agrees to compensate Contracting Provider at the agreed-upon rates for the services assigned to Contracting Provider by ProCare that are billed properly and in a timely fashion. TL - 4 Initial

7 Contracting Provider agrees to submit all invoices to ProCare preferably via ProCare s Website at by , by fax, or at the following address: ProCare Transportation and Language Services Eisenhower Tech Park 4710 Eisenhower Blvd, Suite C-2 Tampa, FL Attention: Accounts Payable billing@theprocare.com Fax: (813) Contracting Provider agrees that all invoices must be presented in a timely manner (within hours of date of service). Invoices received after 60 days of the initial date of service on that invoice shall be held for payment until such time as ProCare has been fully reimbursed by its Client, and can delay payment for up to 90 days. Penalties up to 10% on total bill will apply for any delayed billing. Invoices received after 90 days from the original date of service on invoice will not be considered for payment and will be returned. Contracting Provider agrees that all invoices and receipts, including tolls for services, will clearly state the dates of and type of service provided along with the Injured Worker s name, locations, mileage, wait time, and any additional authorized fees. Incorrect or missing information will delay payment process. Contracting Provider agrees to report final appointment length and/or any additional authorized fees to ProCare within 24 hours of completion of the assignment. Appointment information received more than 72 hours after the assignment will be adjusted on the invoice to Contracting Provider s minimum hourly rate. Mileage is determined using Google Maps. This mileage will be included on the referral authorization form sent to the Contracting Provider. If Contracting Provider disagrees with the mileage listed on the referral authorization form, Contracting Provider must notify ProCare within 24 hours of the transport to justify any differences. Mileage will be paid based on the referral authorization form from ProCare. ProCare does not pay for Patient No-Show claims unless approved prior to the driver leaving the pick-up location. ProCare will consider the Contracting Provider/driver a No-Show if he/she does not arrive as scheduled. In the event of an Injured Worker No-Show, ProCare will reimburse the Contracting Provider the agreed upon No-Show amount indicated on the referral authorization. Contracting Provider agrees to cooperate with ProCare to resolve questions concerning the accuracy and completeness of billings and to make available to ProCare, during normal business hours, such information and records as may be necessary to resolve the questions and disputes. INDEMNIFICATION Contracting Provider agrees to indemnify ProCare against the negligent acts of Contracting Provider s employees acting within the scope of their employment. TL - 5 Initial

8 COMPLAINTS AND GRIEVANCES All complaints and grievances will be fully investigated and resolved to the satisfaction of ProCare management. Contracting Provider agrees to cooperate and participate in such procedures until such complaints and/or grievances can be resolved. CONFIDENTIALITY ProCare and the Contracting Provider understand and agree that all information, records and inquiries obtained during the course of providing services to ProCare customers are privileged and confidential. To the extent required by law, and other than information provided under the normal billing process, Contracting Provider shall keep confidential and not disclose any information related to ProCare or its customers for any purpose whatsoever. ProCare and the Contracting Provider understand and agree that the right to information and records of injured workers is governed by state and federal law regarding the confidentiality of medical records including, but not limited to, The Health Insurance Portability and Accountability Act of 1996 ( HIPAA ). Each party shall comply with all such laws and regulations in the performance of their respective obligations under this Master Agreement, with the minimum standards attached to any Supplemental Agreement(s). MISCELLANEOUS TERMS This is a Contract for Professional Services, and Contracting Provider shall not assign or otherwise transfer any interest in this Agreement without the prior written consent of ProCare. Both parties enter into this agreement as Independent Providers and nothing contained in this Agreement shall be construed to create or imply a partnership, joint venture, agency or employment relationship between the parties. The invalidity or enforceability of any terms or conditions of this Agreement shall not affect the validity or enforceability of any term or provision, and the remainder of this Agreement shall continue in full force and effect. By signing this Agreement, Contracting Provider indicates that it has read and understands the Agreement.\ ** Please list ALL company names that will be covered under this contract. Attach an extra sheet if necessary. ** {CONTRACTING PROVIDER} Signed: Name: Title: Date: {PROCARE, INC.} Signed: Name: Title: Date: TL - 6 Initial

9 INTERPRETATION PROVIDER RATE SHEET Professional Charge $ /hour Professional Time ( hour minimum) Other Charges Travel Time included in professional time, $ _/mile No Show Flat Fee $ (no additional mileage reimbursed) Language(s): Coverage Areas (i.e. Counties): IMPORTANT: The Interpretation Summary Invoice must be completed and submitted within 24 hours of a completed assignment for payment processing. Invoices may be submitted online at or completed in Word and ed to billing@theprocare.com or faxed to Please note there are penalties for late submissions, which are outlined under the section of the Interpreter Agreement entitled Invoicing/Payment of Services. Tolls/parking/additional expenses must pre-authorized and receipts must be submitted in order to be reimbursed. *****ALL RATES ARE SUBJECT TO PROCARE APPROVAL***** Please contact our Provider Relations Department with any questions about our reimbursement rates. I have read, understand and agree to the above rates and policies. All rates are subject to approval by ProCare, Inc. Interpreter Printed (Typed) Name Date Rates Accepted Interpreter Signature ProCare Signature

10 Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. 2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner. Other (see instructions) 5 Address (number, street, and apt. or suite no.) 6 City, state, and ZIP code 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.) Requester s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Part II Certification Under penalties of perjury, I certify that: Social security number or Employer identification number 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following: Form 1099-INT (interest earned or paid) Form 1099-DIV (dividends, including those from stocks or mutual funds) Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) Form 1099-S (proceeds from real estate transactions) Form 1099-K (merchant card and third party network transactions) Date Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) Form 1099-C (canceled debt) Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2. By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information. Cat. No X Form W-9 (Rev )

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12 From: ProCare THIS IS AN EXAMPLE OF OUR TL AUTHORIZATION FORM This authorization number must be submitted on your invoice Patient s Name Subject: APPOINTMENT DATE: 7/12/2013/ PO#: / Test Patient/ Authorization Confirmation Message: HERE IS AN APPOINTMENT FOR AT 2:00 PM. *Spanish OnSite* QUOTED AT YOUR CONTRACTED RATES + (10 Travel Miles). THANK YOU, Dispatch THIS IS WHERE ANY SPECIAL INSTRUCTIONS FOR THIS APPOINTMENT WILL BE. Authorization Information: Spanish TL OnSite DATE OF SERVICE 7/12/ Friday Here are the trip details such as language, appointment date, time and location. APPOINTMENT TIME: 2:00 PM Doctor's Office 456 Main St. TAMPA, FLORIDA PAYOR INFORMATION (PLEASE SEND BILLS TO THIS ADDRESS AND INCLUDE AUTHORIZATION # WITH INVOICE) Payor Name: ProCare Inc Payor Address: 4710 Eisenhower Blvd, STE C-2 Payor City: TAMPA Payor State: FLORIDA Payor Zip: Payor Phone: (813) Payor Fax: (813) Payor billing@theprocare.com PROCARE AUTHORIZATION/PO#: NO OTHER FEES WILL APPLY TO THIS ASSIGNMENT. IF THERE IS A DISCREPANCY WITH THE

13 ABOVE QUOTE WE NEED TO BE NOTIFIED WITHIN 24HRS AFTER THE ASSIGNMENT IS COMPLETED (ALL MILEAGES ARE CALCULATED PER GOOGLE MAPS. 24HR DISCREPANCIES WILL NOT APPLY TO MILEAGE CHANGE REQUESTS WHEN USING OTHER SEARCH ENGINES TO CALCULATE MILEAGES) If you have any questions or concerns please contact our customer service department. Phone: (813) Fax: (813) The information contained in this message may be CONFIDENTIAL and is for the intended addressee only. Any unauthorized use,dissemination of the information, or copying of this message is prohibited. If you are not the intended addressee, please notify the sender immediately and delete this message.

14 Attention All ProCare Providers! Dear Provider, Using ProCare s user-friendly Website at you may submit ALL of your Transportation Invoices as well as your Interpretation Summary Forms in just a few clicks! Simply follow the steps below: 1) Log onto your computer. On your address bar, enter 2) Click on the Providers Tab. 3) Under WELCOME EXISTING PROVIDERS, you will find two links: Transportation Interpreter 4) Choose the correct form for the service you provided. 5) Using the TAB key, enter the information requested under the Provider Information section of the form. (*) is a REQUIRED field; you must enter the REQUIRED information before you can proceed 6) NOTE: To get started on the Transportation Details section of the Transportation Invoice Form, you must choose a DOS for each row entry. You must enter a number value in each field. If a field does not apply to you, please enter "0." Once all your information has been entered, it will calculate a Total Due. 7) Click the Submit button at the bottom of the page. ProCare strongly recommends the use of this website for ALL your invoice submissions. This is a fast and secure way of ensuring timely receipt of your invoices. NO MORE FAXING, ING or SNAIL MAILING! PLEASE NOTE: Your payment process will start on the day that you submit your invoice via ProCare s Website. Please allow your full payment term before calling ProCare for payment status. DUPLICATE SUBMISSIONS WILL DELAY YOUR PAYMENT! If you have any questions regarding the above information, please billing@theprocare.com. Thank you, ProCare s Accounts Payable Team

15 Interpretation Summary/Invoice Company Name: Full Name of Interpreter who provided service: Certification number (if applicable): Date: Patient s Information Name: Trip ID#: Address: City: State: Zip: Date of Service: Facility Name: Address: City: State: Zip: Appointment Status: Completed/Non-Completed (If not completed please indicate reason): Start Time: Stop Time: Next Office Visit(s) : Interpreter s Starting Address: Mileage: Hours Billed: